Provider Demographics
NPI:1720212392
Name:HERBERT ICHINOSE, MD APMC
Entity Type:Organization
Organization Name:HERBERT ICHINOSE, MD APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ICHINOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-781-9005
Mailing Address - Street 1:1361 ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3009
Mailing Address - Country:US
Mailing Address - Phone:985-781-9005
Mailing Address - Fax:985-781-9007
Practice Address - Street 1:1361 ENGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3009
Practice Address - Country:US
Practice Address - Phone:985-781-9005
Practice Address - Fax:985-781-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.008092246Q00000X, 246QH0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyGroup - Single Specialty
No246QH0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHistologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1107921Medicaid
LA1107921Medicaid
LA52893Medicare PIN